Impact of Stress On Operating Theatre Personnel

Impact of Stress on Operating Theatre Personnel: a Literature Review
Impact of Stress on Operating Theatre Personnel
A project submitted in partial fulfillment of the

BSc (Hons) Degree in Intra and Perioperative Practice
ALI ALAMRI
May 2010
Department of operating Department

Practice
School Healthcare Studies
Cardiff University
Cardiff CF14 4XN
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ABSTRACT
The fact that workers throughout the world are often stressed is getting increasing
recognition (Cox et al., 2000). Stress reduces job satisfaction, increases negative feelings, and
produces symptoms of physical illness, if not the physical illness itself. Globalization of the
economy and intensification of competition in the ongoing battle for market share and
survival, pressure mounts on workers (Hoel et al., 2002). Nearly one third of the employed
populations in most developed countries report high or extreme levels of stress (ILO, Geneva,
2002). Potential harmful effects of stressful workplaces have been gaining increasing
recognition from the International bodies, including the World Health Organization (WHO)
and the International Labor Organization (ILO) (Clarke & Cooper, 2004). Estimated costs of
workplace stress to employers in terms of decreased performance, reduced productivity and
quality, more accidents and injuries, increased health care costs, and higher absenteeism and
turnover, are estimated to be $200-300 billion (Hobson, Kesic & Delunas, 2001, p. 47; cf.
Karasek & Theorell, 1990). U.S. industry loses approximately 550 million working days
annually due to stress-related absenteeism (Ball, 2004; Danna & Griffin, 1999). The National
Institute for Occupational Safety & Health estimates that 40% of the U.S. workforce is
affected by stress, making it the No. 1 cause of worker disability (Wojcik, 2001). It is no
wonder that a great deal of empirical research has focused on workplace stress (Barling &
Kelloway, 2005; Cooper, Dewe & O'Driscoll, 2001; Clarke & Cooper, 2004).
This study examines the impact of stress on operating theatre personnel. Over the last
few years, a considerable amount of public concern and empirical research has been devoted
to the issue of job-related stress, both within the United States and globally. For this purpose,
a literature review based research methodology was used with qualitative research design
with which the researcher seeks to explain the impact of work-related stress on operating
theatre personnel.
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Table of Contents
CHAPTER ONE-INTRODUCTION………………………………………………. .5
Development of the Stress Concept………………………………………………... 5
Job Insecurity………………………………………………... ……………………..7
Lack of Empowerment………………………………………………... ……………8
Stress Outcomes………………………………………………... …………………..8
CHAPTER II LITERATURE REVIEW…………………………………………....10
Work-Related Stress………………………………………………... ……………...10
Person-Environment Fit Theory………………………………………………... ….11
Putting it all Together………………………………………………... …………….11
The History of Hospital Design………………………………………………......... 13
The Nightingale Era………………………………………………....……………....14
The Rise of the Mega Hospital………………………………………………... …...14
Current Trends………………………………………………... ……………………16
Implications of these Literatures for the Present Study……………………………..17
The Gendered Nature of Nursing Work……………………………………………..17
Nursing………………………………………………... ……………………………18
Human/Cultural Geography………………………………………………... ………21
Work-Related Stress and the Physical Work Environment…..……………………..22
Research Using Person-Environment (PE) Fit Theory……………………………...22
Implications of these Literatures for the Present Study……………………………...23
CHAPTER THREE-METHODOLOGY…………………………………………….25
Rationale for the Study………………………………………………... …………….25
Limitations and Delimitations………………………………………………....……..26
Contribution of the Study………………………………………………... ………….26
Research Design………………………………………………... …………………...27
Data Collecting and Analysis………………………………………………... ……...27
CHAPTER IV: DISCUSSION OF THE ARTICLES………………………………..28
CHAPTER V: CONCLUSIONS………………………………………………... …..36
REFERENCES……………………………………………………………………….38
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CHAPTER ONE-INTRODUCTION
Development of the Stress Concept
Work environments in operating theatre are considered problematic and a significant
factor that contribute to the operating theatre personnel shortages (Buerhaus, Needleman,
Mattke & Stewart, 2002; Needleman, Kurtzman, Mark, Melichar & Steinwachs, 2004;
Sochalski, 2002). They are also considered problematic in terms of patient safety (Page,
2004). Regulatory, policy and professional organizations have repeatedly called for
significant improvements in hospital work environments. Such improvement in work
environments is considered a key factor in retaining a vital healthcare workforce. Its
importance stems from an increasing amount of evidence that professional, high quality staff
is an essential component in achieving desired patient outcomes (Aiken, Clarke, Sloane,
Sochalski & Silber, 2002; Cho, Ketefian, Barkauskas & Smith, 2003; Knaus, Draper, Wagner
& Zimmerman, 1987; Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, 2002; Unruh,
2003).
However, there is an absence of significant studies examining the stress and its impact
on operating theater personnel due to a difficulty in conducting research on this topic arising
from discrepancies in how stress is defined and operationalized (Briner and Reynolds, 1993;
Cooper et al., 2001; Di Martino, 1992). Sometimes “stress” is equated with excessive and
deleterious pressures on the person (National Institute for Occupational Safety and Health,
1999). Alternatively, it may mean any pressure or challenge, even those that are stimulating
and potentially beneficial to development. Stress in this second sense is what Selye (1950)
refers to as "eustress." It energizes us psychologically and physically, and motivates us to
learn new skills and master our jobs. It is a source of intrinsic job satisfaction and
psychological development (Pinder, 1984, p. 59). However, excessive levels of stress
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constitute what Selye calls “distress,” which is unpleasant and harmful to the individual. In
the recent academic literature stress is most often used to mean distress, that is, the harmful
psychological and physical responses to excessive and persistent stressful conditions.
Stress has been variously viewed as an independent variable, a dependent variable
(Cox, 1985) and a “process” (Cooper et al., 2001). Recent writings tend to view stress as
resulting from the interaction or transaction between individuals and their situation (Di
Martino, 1992; Cooper et al., 2001, p. 3; Cox, 1993). It can be considered the perceived
imbalance between internal and external demands facing the individual coupled with the
perceived inability to cope. This experienced stress is influenced by the nature and the extent
of the demands, the characteristics of the person, the social support available, and the
constraints under which the coping process takes place (Cox et al., 2000).
View of stress as the entire stress experience, including both "stressors" (pressures
and demands in the situation), and “strain” (the individual's negative responses to stressors)
shared by some authors only complicates matters (Jex, Beehr and Roberts 1992;
Viswesbaran, Sanchez and Fisher, 1999, p. 315). Other writers use the term stress as
synonymous with strain, which is the usage adopted for the purpose of this paper. Through
out the following discussion “stress” refers to the individual's response to conditions, and
involves the experience of pressure, distress, imbalance, lack of control, etc. Stress outcomes
are the results of stress such as depression, sleep disturbance, fatigue, erratic behavior, and
physical illness.
Another related term is “burnout.” This term refers to the condition of individuals
who have experienced high levels of stress for prolonged periods of time (Cooper et al.,
2001; Maslach, 1982). Burnout is considered to have three components: emotional
exhaustion, depersonalization, and lack of personal accomplishment (Maslach & Jackson,
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1981). Most of the researches on the causes of burnout apply to stress, but burnout itself is
distinct in as much as it refers only to extreme levels of experienced stress.
Prolonged periods of (dis)stress have been found to cause job dissatisfaction, painful
emotional states, and depression (Cooper et al., 2001). Stress has physical reactions such as
fatigue, irritability, sleep disturbances, and poor health (Hogan & Overmyer-Day, 1994). It
hurts work performance, causing absence, lateness, turnover, compensation claims, reduced
productivity, and poor work quality (Nelson & Quick, 1996).
Job Insecurity
Job security is often defined in a narrow sense as whether or not an employee will
lose his/her job and have to exit the organization (Probst, 2003). Greenhalgh and Rosenblatt
(1984) view it in a broader sense and include any unexpected and undesired changes,
including restructuring, demotion, job change within one's company, or transfer to another
department. They define job insecurity as "a perceived powerlessness to maintain desired
continuity in a threatened job situation." Given their uncertain job tenure and probable
unfamiliarity with company politics, foreign employees are likely to experience insecurity in
a broader sense because job restructuring may get done without their input, or they may be
reassigned to positions or units that others avoid. They are often left out of informal
communication networks and generally are less likely to hear in advance about possible
changes and threats. Indeed, it seems likely that a cloud of uncertainty will hang over their
position in their company.
It is normal for employees to deal with employment uncertainty by working harder
and trying to gain favor of their managers. Else, they may become resigned and attempt to
repress the feelings of insecurity. Either response requires time and energy and if kept up
long enough will generate fatigue and psychological distress. Most of the research has found
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that perceived job insecurity is associated with stress (Gillespie, Walsh, Winefield, Dua &
Stough, 2001; Pollard, 2001; Sethi, King & Quick, 2004). Mak and Mueller (2000) find it
related to four indicators of "strain" - vocational, psychological, interpersonal and physical. It
is associated with stress-related affective states such as job dissatisfaction, hostility, anxiety,
and depression (Cartwright & Cooper, 1993; Kuhnert et al., 1989; Roskies & Louis-Guerin,
1990). Sverke, Hellgren and Naswall (2002) conducted a meta-analysis covering 72 studies,
with 86 independent samples, dealing with the effects of job security on workers. While they
did not include "stress" in their survey, their results showed consistent negative correlations
(corrected for attenuation) between job insecurity and stress-related outcomes such as job
satisfaction (r = -.407), physical health (r = -.159), and mental health (r = -.237). These are
the measurement variables that they used for analysis
Lack of Empowerment
Earlier researches have found that perceived powerlessness is a source of stress (Jones
& Fletcher, 1996; Leana & Florkowshi, 1992; Wagner, 1994). Karasek's (1979) demands
control model suggests that lack of ability to control one's job environment is key. Stress
occurs when high job demands and pressures are combined with a perceived inability to
influence the work process (Fox, Dwyer & Ganster 1993; Totterdell, Wood & Wall 2006).
This creates anxiety about the consequences of poor job performance. Karesek's original
model proposed interactive effects of job control/empowerment: that is, stressors create
actual strain when coupled with low control. Research has tended to support additive rather
than interactive effects (Cooper et al., 2001, p. 137).
Stress Outcomes
Research has found that stress has a number of harmful effects on employees
(Bourbeau, Brisson & Allaire, 1996; Cartwright & Cooper, 1993; Sverke, Hellgren &
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Naswall, 2002). Three of the most often mentioned harmful effects are reduced job
satisfaction, poor emotional states such as depression, and deterioration of physical health.
Stress reduces intrinsic job satisfaction because it associates the job with painful outcomes
(De Cuyper & De Witte, 2007; Hodson, 1991; Leiter & Harvie, 1996; Stamper & Johlke,
2003). It may also decrease job performance and perceived value of rewards - thus reducing
extrinsic satisfaction. Indeed, highly stressed workers have been found to be less productive,
make lower quality decisions, and be more absent from work (Boyd, 1997; Price &
Hooijberg, 1992). Stress can hurt social satisfaction by making it difficult to communicate
and interact with others for the stressed individual.
Stress leads to negative emotional states and even to serious depression (Burke et al.,
1996; Cooper & Cartwright, 1994; Frese, 1999; Van Yperen & Hagedorn, 2003). Prolonged
stress can also lead to physical health problems: fatigue, sleep disturbances, headaches,
backaches, high blood pressure, immune system suppression, and heart disease (Cooper &
Cartwright, 1994; Ertel, Peck, Ullsperger, Von Dem Knesebeck & Siegrist, 2005; Guglielmi
& Tatrow, 1998; Kuhnert, Simms & Lahey, 1989; Tytherleigh, Jacobs, Webb, Ricketts &
Cooper, 2007). Stress-related symptoms now account for about 60 per cent of visits to
primary care physicians (Johnson & Indvik, 1996). Manning, Jackson and Fusilier (1996)
found that stress was related to higher medical expenditures. Workers experiencing poor
psychological and physical health are less productive, make worse decisions, are more prone
to be absence, and make diminishing contributions to the organization (Boyd, 1997; Price &
Hooijberg, 1992).
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BACKGROUND OF THE STUDY
This chapter offers a detailed analysis of the background of the study and critically
reviews the previous studies on the subject of stress among healthcare personnel, especially
the personnel working in operating theater environment.
Work-Related Stress
Work-related stress is also known as work stress, job stress, or occupational stress. It
is defined as “the harmful physical and emotional responses that occur when the requirements
of the job do not match the capabilities, needs, or resources of the worker” (Sauter, et. al.,
1999). Occupational health researchers consider it to be a significant factor in negative
organizational outcomes such as diminished productivity, absenteeism and turnover, as well
as negative worker outcomes such as poor job performance, job dissatisfaction, and health
problems (Brisco, 1997; Caplan & Van Harrison, 1993; Dunham, 2001; McLean, 1979). The
National Institute for Occupational Safety and Health (NIOSH) has opined that it is one of a
wide range of hazards faced by healthcare workers (NIOSH safety and health topic: Health
care workers.).
Hospital nursing is recognized as a high stress occupation (Lawrence & Lawrence,
1987; McNeely, 2005; Wheeler, 1998; Wolfgang, 1988). Registered nurses working in
operating theaters are reporting excessive levels of work-related stress (WRS) due to
inadequate staffing, poor work design, and poor workforce management practices (Aiken et
al., 2001; Aiken, Clarke, Sloane, Sochalski & Silber, 2002; Muncer, Taylor, Green &
McManus, 2001). Role conflict and ambiguity, family demands, and excessive patient
expectations also play a role in WRS (Hoffman & Scott, 2003; Wheeler, 1998). The extent to
which the physical work environment may be contributing to nurses' WRS has not been
studied.
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Person-Environment Fit Theory
Environmental psychologists have considered the design of the physical work
environment as an under recognized factor in work-related stress (Heerwagen, Heubach,
Montgomery & Weimer, 1995). They observe that the relationship between the physical
environment and WRS can be studied using Person-Environment Fit (PE-Fit) theory, which
argues that high levels of congruence, that is, a "good fit", is essential between workers and
the physical work environment to minimize WRS. Heerwagen and colleagues argue that two
types of congruence exist— functional and psychosocial. Functional congruence (FC) is
conceptualized as the capacity of the physical environment to facilitate workers' completion
of tasks. Psychosocial congruence (PC) is conceptualized as the capacity of the physical
environment to facilitate workers' psychosocial well-being. Together, functional and
psychosocial congruence constitute environmental congruence (EC), which has not been
studied in hospital nursing work environments. Such a study requires consideration of the
relations between the physical environment, nurses' psychosocial needs within work
environments, and nursing work.
Putting it all Together
Accepting that chronic nursing shortages would continue, the lack of research on the
subject is problematic. Particularly, the goodness of the "fit" or congruence between nurses,
their work, and their physical environments needs to be studied and described (Ulrich &
Zimring, 2004). It is important because the physical environment is a component in theories
related to work-related stress (Smith & Carayon- Sainfort, 1989; Carnevale, 1992); more so
since the significance of the nurse is being acknowledged in patient safety and health care
quality outcomes (Page, 2004).
Examining physical work environments as they relate to nurses and nursing work may
lead to useful theoretical developments and identify interventions to reduce WRS, which may
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help to improve nurses' performance and engagement levels, enhance patient safety, and
improve the quality of care delivered. This could also contribute to a long-term solution to
chronic nursing shortages.
We have used the constructs of environmental congruence as articulated by
Heerwagen et al., the nature of nursing work as articulated in the IOM report "Keeping
Patients Safe" and a Maslovian conceptualization of nurses' psychosocial needs (Maslow,
1943), for undertaking a study examining a specific type of hospital nursing work
environment (medical/surgical units) based on the conceptual framework. The following
research questions are posed:
o How the work environment does impacts the job satisfaction and performance of
nurses?
o What psychological consequences are associated with the work environment stress?
o What is the experience of nurses about stress related to their work environment?
To appreciate as to how the physical environment, nursing work, and nurses'
psychosocial needs relate to the larger issue of work-related stress (WRS), it is necessary to
consider findings of scholars across a number of academic disciplines including nursing,
women's studies and sociology. Some of which employ a positivist view of science and
epistemology that reflects a belief that the human, social world is ordered, lawful and
predictable (Agger, 1998).
Literatures pertaining to physical dimension of hospital nursing work environments
(whether with positivist or non-positivist perspectives) include literature related to:
1) the history of hospital design;
2) contemporary hospital design standards;
3) contemporary research related to hospital design;
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4) nursing work as women's work;
5) the physical work environment;
6) WRS and the physical work environment; and
7) Person-Environment Congruence (PE Fit) theory.
Theoretical and research work related to these topics is presented next, in order to
provide a context for the present study.
The History of Hospital Design
Hospitals as social and cultural phenomena have been examined by historians and
scholars within a number of disciplines including architecture (Verderber & Fine, 2000),
history of medicine (Thompson & Goldin, 1975), contemporary design (Marberry, 2006),
nursing (Dock & Stewart, 1938; Nightingale, 1863 and sociology (Prior, 1988) - Basic
assumptions being that hospitals are complex, socio-cultural phenomena that reflect beliefs
and norms about a variety of issues including health, illness, cause and treatment of disease,
role of women in society, and societal responsibilities in caring for persons with illness and
disease (Dock & Stewart, 1938; Temkin, 2002; Thompson & Goldin, 1975a). Contemporary
historiographers also acknowledge that histories of social phenomena are themselves
complex, heterogeneous, subject to reinterpretation, and influenced by the historian's political
and social worldviews, loyalties, and subjectivities (Carr, 1962; Lerner, 1979; Smith, 1998;
Tosh, 2002). With such caveats in mind, following is an overview of the history of hospital
design.
The Nightingale Era
Florence Nightingale's influence on hospital design in the late 19th century has been
heralded as the next major development in hospital design (Verderber & Fine, 2000). Her
accomplishments in the Scutari Army Hospital in Turkey during the Crimean War led to a
significant and lasting influence on hospital development (Thompson & Goldin, 1975a). Her
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belief in the miasma theory of disease—that illness was caused by foul air and noxious
vapors—and knowledge of the successfully designed British army hospital at Renkoi has
been posited as influencing her theory of hospital design (Gill & Gill, 2005). "Nightingale"
hospitals were located on well-drained land, and consisted of single story pavilion-type
structures no more than 30 feet wide. Large windows were placed between patient beds to
admit light, air, and fresh air. Her influence spread throughout Europe and the United States
where pavilion style hospitals were built over the next several decades.
The Rise of the Mega Hospital
Scholars have argued that the next development in hospital design occurred in the
post World War II years of the 1950's in the United States (Verderber & Fine, 2000). Federal
level legislation (the Hill-Burton Aet) providing federal funds for hospital development led to
a building boom, whose occurrence during a time of accelerating technological development
gave rise to "mega hospitals"—multidisciplinary centers in which patients of all types and
acuities were housed, diagnosed, and treated.
European architect Le Corbusier built various types of structures (housing, office
buildings, etc.) from steel, glass, and concrete, with little or no ornamentation. The style
became known as the International Style and significantly influenced hospital design in the
mid 20 century (Verderber & Fine, 2000). Hospitals were built to be highly functional with a
central core, multiple stories, and linking corridors for supply distribution. Hospital nursing
unit designs also emphasized functionality and their variations were developed to improve
nursing efficiencies including single corridor, dual or racetrack corridor, radial, and cross-
corridor designs. Architect Gordon Friesen also influenced (Weeks, 1961) future hospitals,
which were designed to suit mechanization of the routine trafficking work, using a trolley
delivery system that serviced patient care units from distant kitchens and laundries.
"Interstitial floors", placed between floors housing patients allowed maintenance and HVAC
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(heating, ventilation, and air conditioning) personnel to work out of the patient's view.
Nursing supplies were delivered to the "point of use" within cupboards and closets that
opened two ways to exterior hallways and patient room interiors, that is, the "nurse-server".
Pneumatic tube transport systems further facilitated transport of the multiple small items
associated with patient care (requisitions, paperwork, lab work, etc) across departments.
This approach intended to provide nurses with an ability to spend more time with
patients and a majority of larger hospitals employ these mechanical aids today, although the
development of digital and electronic medical record and report processing is leading to
changes in methods of communication within healthcare systems (Johns, 1997; Steen &
Detmer, 1997). Further, the work environment has significant impact of job satisfaction and
work related stress. So, the better the design of the hospitals, the better performance can be
expected from the nursing staff.
Current Trends
Contemporary trends in hospital design include "patient-centered design", "healing
environments", and “enhancing patient safety”.
Healing Design: Scholars have argued that the "healing design" movement is a
"postmodern" approach that began in the 1960's in England with the rise of the hospice
movement (Verderber & Fine, 2000). "Healing Design reflects a "New Regionalism"
approach to healthcare design that has emerged internationally. It reflects a critical
perspective, and runs counter to the mega-hospital phenomenon. "Healing Design"
emphasizes human-scaled environments that incorporate nature, environmental psychology
principles, and the construct of sustainability (Verderber & Fine, 2000). It is noted that
contemporary hospitals are remembering their obligation to provide "social comfort" and
begun emphasizing aesthetic factors within and around (Hosking & Haggard, 1999).
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The Patient Safety Initiative: The recent publication of a number of U.S. federally
sponsored IOM reports (Committee on Quality Health Care in America, 2001; Kohn,
Corrigan & Donaldson, 2000; Page, 2004) has heralded a new policy emphasis in U.S.
healthcare design—improving patient safety, reducing health care related error, and
improving the quality of care within health care environments.
The IOM report, Keeping Patients Safe (Page, 2004), raises conceptual issues related
to hospital design, including organizational factors, work and workspace design, and patient
acuity. The physical design of work environments is highlighted (Carayon, Alvarado &
Hundt, 2003) in conjunction with the contemporary paradigm emphasizing quality
improvement and the industrialization of health care (Committee on Quality Health Care in
America, Institute of Medicine, 2001; Kohn et al., 2000). Regulatory groups are requiring
responsible parties (administrators, clinicians) to take a systems-engineering approach to
work design that is ongoing, process based, and problem-focused (Joint Commission on
Accreditation of Healthcare Organizations, 1997).
Implications of these Literatures for the Present Study
The implications of the literatures related to the history of hospital design for the
present study are as follows:
1) Relationship of the working environment with WRS;
2) Evaluation of the prevailing views about the nature of health and illness, including
what health care is supposed to "look like" (for example, birthing centers that feature private
suites and a hotel-like ambience
The Gendered Nature of Nursing Work
Another vein of research and scholarly work related to hospital nursing work
environments is the gendered nature of nursing work. This work has been done by feminist
scholars within a number of disciplines including nursing, architecture, human and cultural
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geography, environmental psychology and architecture/design. It will be presented by
discipline, although its very nature makes it somewhat trans-disciplinary.
Nursing
Joan Liaschenko (1994), a nursing researcher interested in the nature of nursing and
nursing work, and who acknowledges a Foucauldian philosophical influence (Foucault,
1975), has argued that nurses now routinely extend the physician's "gaze" within and across
various health care settings. Such an extension impacts the nursing profession's ability to
implement its own more holistic gaze as well as its ability to facilitate patient agency. She has
argued that nursing work, whether carried out in the home or in institutional settings, is
conducted within "gendered space" that reflects “literal and metaphorical space in the social
and political life of societies" (Liaschenko, 1997, p. 51). In a qualitative study in which she
asked experienced, educated nurses to speak about an incident from their practice that
highlights ethical concerns, she found that the delivery of patient care and the execution of
nursing practice were subject to the social and political space occupied by both patients and
nurses. Multiple "spatial vulnerabilities" were found which then significantly impacted both
patients and nurses. These vulnerabilities included poverty, the exploitation of patients to
meet institutional needs, the homogenization of patient identity, and the fragmentation of
patient and family care. After asking, "... what is the place of nurses" and "Do they even have
a place?" (p.52) she argues that, although nurses are seen as both nurturers and executors of
physician orders, the socially reinforced portrayal of nursing work "fails to reveal a whole
domain of absolutely essential work" (p.52) (what she calls complex connecting or relational
work) that "literally keeps the patient cared for and the institution going" (p52).
The reason nursing work is not seen, she argues, is because, "as a society we have
been schooled to see the work of medicine rather than the work of others as most significant
in patient care." (p.52) - this invisibility of nursing work occurs because it is work conducted
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by women, viewed as women's work, and therefore devalued. Nursing work, Liaschenko
argues, becomes at risk of turning into instrumental work that serves more powerful and
visible interests (physicians, administrators, insurers). She concludes by making a case for a
linkage between nursing and human and/or cultural geography because of the scope (local,
global, structural) that this sub discipline can bring to a consideration of care environments.
In a related article, Peter and Liaschenko (2004) note that the construct of proximity,
that is, nearness to patients, is problematic because of the issues related to moral ambiguity
and moral distress that it can elicit—proximity "(can) propel nurses to act, it can also propel
nurses to ignore or abandon" (p218). It may be that proximity itself is not the problem but
rather the deficiencies and inequities within the health care system that is revealed by the
various types of proximities that nurses are able to develop with patients and families. Peter
and Liaschenko argue that nursing needs to bring others (administrators, physicians, policy
makers, and the public) into proximity with patients so that the moral ambiguities can be
better understood and appreciated. They also argue that nurses need more frequent breaks and
quiet areas away from patient care, and that nurses in academia need to teach new nurses how
to "articulate their practice, including the social space they occupy" (p.223). Finally they
argue that a more robust exploration of nursing ethics, especially as it relates to the moral
ambiguity that can develop with proximity to patients, could assist in deescalating the moral
distress that may be a large component of the stress nurses experience in their work.
Malone (2003) has also considered issues encompassing physical space, health policy,
nursing care and nursing ethics - arguing that the ethical integrity of contemporary
professional nursing practice in hospitals is increasingly at risk because the three types of
proximity that hospital nurses have traditionally had with patients (physical, narrative, and
moral), and that are fundamental to ethical nursing practice, are being threatened by
contemporary health care management practices and policy. In particular, "hospital nursing is
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spatially vulnerable (and that) a taken-for granted proximity to patients...” is acutely
threatened by the localized special and power dynamics of macro-originated economic and
ideological pressures." (p. 2318). Malone grounds her argument within two theoretical
perspectives: 1) The phenomenological perspective on space and place that argues that place
"grounds our subjective, embodied experience and can only be understood through
experience" (p. 2318) as articulated by Casey (1993) and Malpas (1999); and 2) Critical and
historical perspectives that address the power relations embedded in place and space
(Foucault, 1975; Foucault, 1977; Lefebvre, 1991; Massey, 1994).
Malone portrays professional nursing practice as a relational one in which the nurse
develops three types of proximity with patients—physical, narrative, and moral. Physical
proximity is a proximity that develops when a nurse gains particularistic knowledge about a
patient's body. Narrative proximity is a proximity that develops when a nurse gains
particularistic knowledge about a patient's background, i.e. his or her "story". Moral
proximity is a proximity that develops when a nurse has developed both a physical and
narrative proximity with a patient, and because of these proximities (knowledge), is able to
infer what a patient may desire or wish, but may be unable to articulate. She argues that these
proximities are nested within each other—physical proximity enables narrative proximity,
which then enables moral proximity—and that these three types of proximities are limited by
contemporary forces in health care, which include: 1) chronic nursing shortages, the use of
flexible staffing structures, and the use of lesser-trained and lesser-empowered health care
workers; 2) shorter lengths of stay, structured forms of nurses' notes (charting by exception),
and multiple care settings; and 3) abstract classification systems and standardized plans of
care that reduce patient care down to a series of tasks to be managed and/or outcomes to be
achieved. Malone calls this evolution "distal" rather than "proximal" nursing and believes that
it may lead to a "we're just running the trains" mentality within the profession (p. 2324).
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Human/Cultural Geography
Gavin Andrews, a geographer within the School of Nursing at the University of
Toronto, has echoed and reinforced Liaschenko's call for a link between nursing and
geography, calling for a "geography of nursing" linking the broad constructs of nursing,
people, health, space, and place (Andrews, 2003 a). He argues that Nightingale used
geographical references to space and place within Notes on nursing: What it is and what it is
not, such as her articulation that, for proper healing, patients need, among other things,
ventilation, warmth, light, and proximity to nurses (Andrews, 2003b), and that given the
increasing diversity of places and spaces in which nursing occurs, an emerging area for a
trans-disciplinary scholarship linking nursing with health geography could begin to examine
the dynamic relationship between people, health, and place (Andrews, 2002).
Health geography emerged in the 1990's as a theoretical and social development of
medical geography, an area of 20th century research that has traditionally addressed spatial
and geographical issues related to disease distribution as well as the distribution,
accessibility, and utilization of health care services facilitated by humanistic and Marxist
oriented critiques of the prevailing views of geography as spatial science that emerged in the
1970's (Andrews, 2003). Andrews notes that work by Liaschenko has already begun to
examine how patient care settings reflect larger economic, social, and cultural issues. Other
scholars have noted that the discipline of cultural studies may be a vantage point to study the
complex interrelationship between power, technology, culture, and space (Poland, Lehoux,
Holmes & Andrews, 2005).
One study pertinent to a consideration of hospital nursing work environments that
reflects the geography of nursing emphasis called for by Andrews is a study of English
hospital nurses conducted by sociologists (Halford & Leonard, 2003). It explores how the
material space within hospital settings influenced the construction and performance of
21
nursing identities. Repeated observations were made of staff level nurses within a large 700-
bed district hospital and smaller 60-bed community hospital. Observation sheets were used to
record details related to the physical environment, the individuals present, activities,
movements, and conversations that the researchers had with the nurses. The findings included
that, in comparison to physicians, nurses had less access to various hospital spaces and that
many of them were virtually confined to the wards in which they worked. Additionally, the
public "ward space" of the units was the only space that many nurses had access to and that
within these ward spaces, little or no space that was allocated to them as specific individuals.
They also found that nurses were allocated significantly smaller amounts of private space
than physicians. They concluded that the material space within the hospital work
environments did have implications for the construction and performance of the nurses'
workplace identities.
Work-Related Stress and the Physical Work Environment
Work-related stress (defined as work-related physical and mental strain) is accepted
as a contributing factor in negative individual and organizational outcomes such as poor job
performance, absenteeism, job dissatisfaction, turnover, and health problems (Brisco, 1997;
Caplan, 1975; Heerwagen et al., 1995; Theorell & Karasek, 1996). Worker health and
organizational productivity has also been linked (Murphy & Cooper, 2000). The role of the
physical work environment on worker health and productivity and organizational health and
productivity has also been theorized (Becker, 1981; Becker & Steele, 1995; Carnevale, 1992;
Vischer, 1996). The health of work environments has been theorized as varying along a
continuum; healthy work organizations promote and/or maintain worker health and
organizational productivity. Healthy work environments are conceptualized as ones that
successfully address the issue of work stress. Karasek has theorized that employee
22
involvement and input into the work environment, reduces the risk of heart disease among
workers (Karasek, 1990).
The management of occupational stress through changes in the physical work
environment is the subject of a review (Heerwagen, et al., 1995), which arguea that although
the issue of work stress is of critical importance, organizational leaders all too often assume
that the root causes of these problems lie within individual workers, not the physical
environment. Australian researchers reached a similar conclusion in a case study of work
stress within a public hospital (Trubshaw & Dollard, 2001).
Research Using Person-Environment (PE) Fit Theory
PE Fit theory has been proposed as a theoretical framework for addressing work
related stress (Caplan & Van Harrison, 1993; French, 1982; Van Harrison, 1978). The roots
of the theory have been attributed to Kurt Lewin's Human Needs Field theory (Lewin, 1951)
and Henry Murray's Needs-Press theory of personality (Murray, 1938). Lewin theorized that
human behavior was a function of the person within the environment. Murray envisioned
people as having basic needs (for safety, socialization, privacy, accomplishment, etc.), while
the environment exerted various types of "press" or demands on them. PE Fit theory argues
that people within their environments exhibit varying levels of congruence or "fit". When a
person's needs match his or her environmental press, it results in congruence or a "good fit",
which facilitates the satisfaction of needs and attainment of goals. A "bad or poor fit" hinders
the satisfaction of needs and attainment of goals leading to strain, dissatisfaction, and/or other
negative outcomes.
Implications of these Literatures for the Present Study
Present study draws a number of implications from the researches using PE Fit theory.
First, the concept of congruence or "fit" has been judged to be useful by a variety of
researchers and used to assess not only individual productivity in work settings, but also the
23
health and well-being of individuals in varied settings. The impact of the physical work
environments on work-related stress in operating theatres has not been examined. This would
seem to indicate that the use of the theory in nursing work environments would not be
inappropriate. However, if the impact is significant, theory-based interventions can be
developed and tested for their impact. Types of attributes within physical work environments
that a nurse would consider important and desirable, to support their productivity and well-
being have not been examined, either. This is noteworthy given that nurses constitute the
largest percentage of clinical workers within hospital settings and a chronic nursing shortage
is expected to continue.
24
CHAPTER THREE-METHODOLOGY
Rationale for the Study

The objective of this study was to assess the impact of job-stress on operating theatre
personnel. As such a qualitative study design using literature review method was used to
explain the impact of work-related stress on operating theatre personnel and understand the
factors causing stress. In the process the study sought to examine major factors causing stress,
conflicts, and solutions to these conflicts as well as workplace conditions in the healthcare
profession and the difference of workplace conditions between healthcare profession and
other professions.
Useful articles and books featuring balanced and valid studies were both identified
and critically appraised (Rees 2003) - reviews that had been published on the study topic by
accredited scholars and researchers (Ridley 2008) directly related to the study question.
Each article was subjected to critical questioning which included the following:
• Is the article related to our topic?
• Is the topic clearly defined?
• Is it important and clearly established?
• Have all possible related factors analyzed and researched?
• Has the author evaluated relevant articles by verifying references?
• How useful was the article?
(Hart 1998) stated that the review should compare and contrast different authors’
views on one issue, by gathering similar articles by different authors with the same
conclusions and criticizing the methodology of the article.
25
The search strategy to scan research articles databases was adopted using the Metlib
searching tools, Pubmed, Web of Science, Amed (Ovid), British Nursing Index (Ovid),
Cinahl, Allied Health Literature (EBSCO), Embase, Scopus (Elsevier) Web of Knowledge
and Zeto current articles relevant to “Impact of Stress on Operating Theatre Personnel”.
Keywords and the search terms found in the proposal, conflict, operating theatre, job
stressors, stress, healthcare, nursing, occupational stress etc. were used. The other search
term was ‘occupational stress and”. A total of 100 references cited in articles were accessed
and reviewed for additional publications targeting the period from the year 2000 onwards.
For example ‘Symptoms of stresses” released 10 articles whereas ‘sources of work stress’ 50
articles. The articles which were found relevant to the study were recorded and Google
scholar was used to read these articles. Of all researches conducted, 20 were relevant to the
study. Some articles will be reviewed while others will be used to compare between authors’
views. Basic search was carried out combining subjects with ‘and’ or ‘Or’.
Limitations and Delimitations
This study was carried out via the literature review methodology. Use of this method
depends upon the accuracy of the research conducted, attitudes of the researcher, and other
relevant information. Some notable limitations to be acknowledged are, the validity of the
research work already done and that the responses may be unnatural due to the subjective
perceptions of the researchers. Finally, it is indirect research so a direct contact with the
operating theatre personnel would have been more valid
Contribution of the Study
The literature used provides an analysis of the factors causing stress and its impact on
operating theatre personnel. The extensive literature on stress definitions, stress development,
workplace stress, healthcare and nursing profession, interpersonal conflicts in the operating
26
theatre departments, the impact of stress on performance of the operating theatre personnel
has been primarily focusing on the operating theatre personnel. Since Taylor (1911)
developed the concept of scientific management in the early 1910s, the notion of
standardizing job-related tasks has changed the way organizations function around the world.
By simplifying the task each worker performs, Taylor’s principles allow organizations to
apply systematic coordination methods in order to optimize productivity (Muchinsky, 2003).
Research Design
This study explored stress factors and impact of stress on the operating theatre
personnel. The primary research question explored was: What impact does stress has on
operator. As a methodology design the study used a qualitative studying design, i.e. literature
review method to explain the impact of work-related stress on operating theatre personnel.
The finally selected articles were examined and critically analyzed for rigor of the research
and identified themes that recur across settings and can be applied to staff in the operating
theatre. Additionally, correlation analyses were conducted to examine the relationships
between the challenges faced by the operating theatre personnel and their impact on
performance and health. Review of the latest research and co-relate them for a specific
purpose has been done. By gathering information that “describes the nature and extent of a
specified set of data ranging from physical counts and frequencies to attitudes and opinions,”
researchers can analyze problems through systematic, representative, objective, and
quantifiable research design (Isaac & Michael, 1995).
Data Collecting and Analysis
The selected articles were reviewed and related to analyze the job stress factors and
their impact on operating theatre personnel. The selection of literature review based research
design was the best approach for the data collection process of this study as the researcher
27
intended to offer a broader explanation of work related stress covering a variety of previous
researches. Mostly, in the nursing fields, researchers have relied on the meta analysis or the
critical literature review methods for data collection and analysis as it offers greater
flexibility and choice of collecting data from wider perspective.
28
CHAPTER IV: DISCUSSION OF THE ARTICLES
The role of workplace health promotion in addressing job stress by Andrew Noblet and
Anthony d. Lamontagne
This article addresses the issue of workplace health promotion. It has been pointed out
that WHP focuses only on the individual and not relate it to the working conditions or
organization. This paper purports to highlight the criticisms of the individual approach to job
stress and examines evidence for developing strategies that combine both individual and
organizational-directed interventions. It also provides a detailed description and develops
initiatives that address both the sources and the symptoms of job stress (Nobel and
Lamontage, 2006, p-1).
It is based on literature review of the WHP and a case study; a call centre located in
Australia (p-2), where poor performance of employees as well as increased rate of customer
complaints was found. Manager of the call centre hired services of a corporate Workplace
Health Promotion company to overcome health related issues of the staff members. On
analyzing the situation committee found that the employees were facing problems at
workplace as they had to attend repetitive calls and callers sometime used abusive language
and they had never been trained to handle such calls. Another major source of poor
performance was mothers worrying about whether their children had got home from school
safely. OAS employed a large number of mothers with dependent children. Realizing the
problem, the company gave their operators a 10 min break around 4 p.m. so they could call
home to make sure that the kids had arrived safely. This strategy alone resulted in a
significant improvement in the service quality and morale.
Discussion Comments on “Occupational stress in nursing” by S. Jowett published in
International Journal of Nursing in 2007
29
This article discusses an earlier article “Occupational Stress in nursing” by McGrath
published in late 1980’s and relates it to the current situation. It is based on literature review
based on the research from 1980 to 2003 and survey results from 171 nurses. The author
confirmed the presence of workplace stress during late 1980’s “every day the nurse confronts
stark suffering, grief and death’ end of the spectrum (Hingley, 1984)”. It confirms that
‘nursing is stressful and that some causes of stress are found in all specialties’. Their analysis
reverberates with a definition of stress, “the reaction people have to excessive pressure or
other types of demands placed upon them. It arises when they feel unable to cope” (HSE,
1999). The study indicates that nurses face considerable work-related stress. The main
finding is that nurses are asked to concentrate on the physical objectives and avoid emotional
demands of the patients. Other main points are powerlessness as they can’t make decisions in
the workplace, as well as lack of acknowledgement of their work by practitioner. Other
factors recognized were working relationships, communication difficulties and the high
workload (Stehle, 1981). Nichols et al. (1981) identified concerns about inadequate support
from senior nursing staff.
Analyzing these articles the author states the present situation which indicates “the
findings are alarmingly familiar” (Worthington, 2001) as 71% of the nurses pointed out the
effects of stress and overwork to be the major health and safety concern. 67% complained of
working overtime every month. Literature reviewed in the article also indicates evidence of
occupational stress among nursing staff; “Stressful situations at work have been seen to
contribute to both anxiety and depression” (Weinberg and Creed, 2000)
Conflict and its resolution in the operating room by Jonathan D. Katz MD (Clinical
Professor)* published in Journal of Clinical Anesthesia (2007)
This article focuses on operating room conflicts, their impact on the overall OR
atmosphere and suggests solutions to resolve the conflicts. The study is based on review of
30
literature regarding conflicts, sources of conflicts, consequences of unresolved conflicts,
operating room conflicts, as well as relevant case studies to explain the interpersonal conflicts
in operating room and its impact on the case.
The operating is a high-stress and explosive workplace where interpersonal conflict
can be recurrent and at times severe “The potential for interpersonal conflict is especially
heightened in the operating room (OR), where a broad range of professionals (physicians,
nurses, technicians) have overlapping and, in many cases, poorly delineated areas of
responsibility” (p-152). “the OR is the only location within a hospital where two coequal
physicians regularly and simultaneously share responsibility for one patient. Decisions
involving life and death are routine, and wrong decisions resulting in adverse outcomes are
subjected to intense scrutiny and retrospective analysis”.
These conflicts sometimes result in cancellation or more accurately, postponement of
a surgical procedure for additional evaluation – it is noted that conflicts over the method of
treatment frequently occur between an anesthesiologist and a surgeon” (p-156).
In the OR, the surgeon is considered to be captain of ship and “At the root of many
anesthesiologist-surgeon conflicts is the archaic doctrine of the captain of the ship. This
concept held that the mere presence of the surgeon in the OR subjects him or her to legal
liability for any negligent acts involving the patient in that room” (p-155).
Disagreement and aggression in the operating theatre By Richard Coe & Dinah Gould (2007)
This is a research study which was conducted to identify the reasons for increasing
incidents of disagreement in OR among professional groups in operating departments and the
incidence of seeming aggressive behavior shown by operating department personnel. The
study was based on a survey conducted by National Health Service operating departments in
31
England, of which 37 departments participated comprising 391 individuals including nurses,
surgeons, and anesthetists and operating department practitioners of all grades.
The study results confirmed the presence of aggressiveness and disagreement among
operating theatre personnel (p-616). 50% of the respondents confirmed occurrence of
aggressive behavior from consultant surgeons while daily disagreements among nurses and
consultants about list management were reported. It was also reported that there exists a lack
of understanding of roles in patient care.
Job satisfaction or production? How staff and leadership understand operating room
efficiency: a qualitative study by E. Arakelian, L. Gunningberg and J. Larsson (2008)
This article focuses on the perceptions of efficiency in operating room by supervisors,
surgeons of the operating department - “Efficiency and productivity play a central role in
managing an operating department” (p-1423).
The study was based on interviews of 21 members of operating department staff and
supervisors in a Swedish hospital. The results show variation of efficiency perception among
different categories of operation room staff. The major finding was that mostly nurses and
assistant nurses defined efficiency as personal knowledge and experience, accentuating the
importance of the work process, while the supervisors and physicians defined efficiency as
completion of an assignment.
Incidence of Metabolic Syndrome among night-shift healthcare workers by A Pietroiusti, A
Neri, G Somma, et al. published September 2009.
As healthcare is a 24 hour service so the medical staff has to perform night duty.
Night-shift work is allied with ischemic cardiovascular disorders. Currently it is not
confirmed whether it may be causally linked to metabolic syndrome (MS), which is a risk
condition for ischemic cardiovascular disorders. This article is a research study to review
32
whether there exist a connection between night-shift work and the development of MS.
Methods: Male and female nurses performing nightshifts, free from any factor of Metabolic
Syndrome were selected and reviewed annually for 4-years to know the development of the
disorder. Male and female nurses doing day duty were also evaluated for the sake of
comparison among both the groups during the same time period. The results indicated that
incidence of MS and relative risk was higher among nigh-shift nurses as compared to nurses
performing day time work. The study confirmed that there exists a risk of developing MS
with night-shift work in nurses.
Occupational stress, job satisfaction, and working environment among Icelandic nurses: A
cross-sectional questionnaire survey by Herdı´s Sveinsdo´ ttir_, Pa´ ll Biering, Alfons Ramel
published 2006
This is a research study conducted to identify stress factors at workplace among
Nurses working in Iceland. The study comprised of a survey which was posted to all
registered nurses and results comprised of responses from 206 nurses both working inside
and outside the hospital.
The survey results confirmed presence of workplace stress among nurses which was
high among the nurses working in the Hospital as compared to those working outside the
hospital. The reasons found are that the nurses working in the hospital have to work more
hours per week, provide more direct patient care, have less opportunity to take lunch breaks
at the appointed time and off the unit, and also there occur staff shortages. Nurses working in
hospitals have also tolerated more unexpected changes in their work schedule.
The researcher has also referenced a report on women’s health from the Icelandic
Ministry of Health and Social Security (2003) which concludes that working women also
perform their household responsibilities for the welfare of family and thus they have to work
33
extra hours. Another reason for overtime for Icelandic nurses is the shortage of nurses in
Iceland.
Sources of Work-Stress Among Hospital-Staff at The Saudi MOH By Badran Abdulrahman
Al-Omar (2003),
This article focuses on the factors causing work-stress as well as its impact amongst
the MOH hospital staff working in Riyadh City, Saudi Arabia. Descriptive analytical research
design was used in the study. The hospital staff including Doctors, nurses, technicians,
administrators, and therapists working at five MOH hospitals was assessed by a questionnaire
distributed among 700 members of the staff, of which 414 responded.
The results are indicated by, “It is clear that the first cause accounted for the variance
in the dependent variable (work-stress level) was the insufficient technical facilities available
to hospital staff” (p-10). The other factors lack of appreciation, long working hours, and short
breaks also cause stress among the hospital staff. Results also indicated that Saudi
participants showed drastically higher level of work-stress as compared to the non-Saudis.
The major impact of work related stress was the tendency to change the hospital,
change the job and quitting the practice, however, no significant relation between the level of
work stress and occurrence of health problems was found.
Occupational stress and its consequences In healthcare professionals: The role of type d
personality by nina ogińska-bulik (2006)
This is a research study aiming at the consequences of occupational stress in
healthcare professionals specifically focusing on Type-D personality. The study used
personality evaluation of 79 healthcare professionals including physicians and nurses through
work evaluation questionnaire, General health questionnaire and Maslach burnout inventory”
The results confirmed that Type-D personality plays an important role to perceive job related
34
stress and its effects on health, “There is a substantial evidence that stress can lead to various
negative consequences for individuals, including somatic diseases, The study group of
healthcare workers suffered from extensive job stress, which was more manifest among
women than in men” (p-113).
It was also found that level of stress is higher in healthcare as compared to other
professions, “The level of stress suffered in this occupation is higher than in other professions
(measured with the same method), e.g., bank workers (M = 90.5), journalists (M = 98.6), and
managers (M = 99.2) [41], mental health disorders or feeling” (p-113).
Research on Psycho neuroimmunology: Does Stress Influence Immunity and Cause Coronary
Artery Disease? By Roger CM Ho,Li Fang Neo, Anna NC Chua, Alicia AC Cheak, and
Anselm Mak,
This is a review of an article which is based on the importance of psycho neuro
immunology (PNI) studies to understand the role of acute and chronic psychological stressors
on the immune system and development of coronary artery disease (CAD). In this article the
researcher proved that psychological stresses cause adverse effects on health and results in
changes in cardiovascular function and development of CAD. It also indicates that, acute and
chronic psychological stressors will increase haemostatic factors and acute phase proteins,
possibly leading to thrombus formation and myocardial infarction. The evidence for the
effects of acute and chronic psychological stress on the onset and progression of CAD is
consistent and convincing. “Chronic stress and associated psychological responses can
activate the hypothalamic-pituitary-adreno-cortical and sympathetic adreno-medullary
systems”. This paper also points out possible research areas and insinuations of early
detection of immunological changes and cardiovascular risk in people under high
psychological stress.
35
Occupational stress and its effect on job performance A case study of medical house officers
of district Abbottabad by Rubina kazmi, shehla amjad, delawar khan* (2008)
This article is a research study which was conducted to evaluate the impact of
occupational stress on job performance. The area of research was Abbotabad District
located in Pakistan. The research was in the form of a survey in which all the 55 house
officers present at the time of research participated. The results of the study confirm the
hypothesis “there is an inverse relationship between job stress and job performance
indicating that there is high job stress in the house officers, resulting in low job
performance”
The results also indicated high level stress for the physician and surgeons working
in surgical and medical wards than those working in other wads (p-136). The factors
causing stress include “job pressure, job description conflict, lack of communication and
comfort with supervisor, job related health concerns, work overload and lack of resources
and overall job performance, which all have negative relations”
Review Psychophysiological biomarkers of workplace stressors by Tarani Chandola *,
Alexandros Heraclides, Meena Kumari (2009)
This article is based on literature review related to the Psychophysical biomarkers of
workplace stressors. The researchers indicate the evidence of association of work stress with
greater coronary heart disease risk. The author reviewed 04 studies on plasma
catecholamines, 10 on heart rate variability, and 16 on post-morning cortisol. The results
indicate that most of the studies conclude that work stress is associated with lower heart rate
variability. The study concluded that work stress is related to high stress responses related to
sympatho-adrenal and HPA axis biomarkers.
36
CHAPTER V: CONCLUSIONS
The purpose of this study was to examine the impact of stress on operating theatre
personnel. Over the last few years, considerable amount of public concern and empirical
research has been devoted to the issue of job-related stress, both within the United States and
globally. There is concern that continually increasing global competition is creating more and
more pressure on workers at every level, which can have significant deleterious consequences
for the workers, their families and organizations. For these reasons, it is likely that operating
theatre personnel will experience heightened levels of stress. Nonetheless, there has been
little published research on stress among operating theatre personnel, either in the United
States or apparently in other countries. The present research is an attempt to fill at least part
of this gap and to pave the way for further research.
Present literature review suggests that the long working hours, lack of appreciations,
interpersonal conflicts, are the primary factors which directly impact on the performance as
well as health of operating theatre personnel. These factors directly affect the performance
and health of the operating theatre personnel and consequently the patient is affected.
These results are entirely consistent with the claim that occupational stress is growing
extensively and has impacts on the job performance as well as personal life and health of the
individual. On the contrary, the three components that seem to be most important for
operating theatre personnel are; belief or interest in the system, personal space, rational shifts
and appreciation for the hard work.
As the risk of running and managing hospitals in the domestic market on commercial
lines has been notably high, and the majority of the hospitals have not been able to recoup
their investments, this research was conducted to explore the current working conditions of
37
operating theatre personnel and the challenges commercial hospitals face in the United States.
The analysis was based on a study of the earlier researches on the subject.
To conclude there is strong evidence of the presence of stress among operating theatre
personnel and its following consequences among them:
• Reduced job satisfaction
• Increased negative feelings
• Symptoms of physical illness
• In many cases actual physical illness.
With commercialization of health care and the growing emphasis of the stake holders on the
bottom line, it is important that the interests of the operating theatre personnel are not lost
sight of and they get the deserved attention free of gender bias.
38
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Impact of Stress On Operating Theatre Personnel

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Impact of Stress on Operating Theatre Personnel: a Literature Review

Impact of Stress on Operating Theatre Personnel

A project submitted in partial fulfillment of the

Department of operating Department

workplace stress to employers in terms of decreased performance, reduced productivity and

Development of the Stress Concept

Work environments in operating theatre are considered problematic and a significant

significant improvements in hospital work environments. Such improvement in work

environments is considered a key factor in retaining a vital healthcare workforce. Its

is an essential component in achieving desired patient outcomes (Aiken, Clarke, Sloane,

refers to as "eustress." It energizes us psychologically and physically, and motivates us to

psychological development (Pinder, 1984, p. 59). However, excessive levels of stress

psychological and physical responses to excessive and persistent stressful conditions.

Stress has been variously viewed as an independent variable, a dependent variable

2001; Maslach, 1982). Burnout is considered to have three components: emotional

exhaustion, depersonalization, and lack of personal accomplishment (Maslach & Jackson,

distinct in as much as it refers only to extreme levels of experienced stress.

productivity, and poor work quality (Nelson & Quick, 1996).

position in their company.

It is normal for employees to deal with employment uncertainty by working harder

related to four indicators of "strain" - vocational, psychological, interpersonal and physical. It

the measurement variables that they used for analysis

than interactive effects (Cooper et al., 2001, p. 137).

and interact with others for the stressed individual.

BACKGROUND OF THE STUDY

the personnel working in operating theater environment.

1999). Occupational health researchers consider it to be a significant factor in negative

organizational outcomes such as diminished productivity, absenteeism and turnover, as well

Hospital nursing is recognized as a high stress occupation (Lawrence & Lawrence,

Person-Environment Fit Theory

Environmental psychologists have considered the design of the physical work

environment as an under recognized factor in work-related stress (Heerwagen, Heubach,

types of congruence exist— functional and psychosocial. Functional congruence (FC) is

conceptualized as the capacity of the physical environment to facilitate workers' completion

of tasks. Psychosocial congruence (PC) is conceptualized as the capacity of the physical

environment to facilitate workers' psychosocial well-being. Together, functional and

environments, and nursing work.

Putting it all Together

Zimring, 2004). It is important because the physical environment is a component in theories

quality outcomes (Page, 2004).

chronic nursing shortages.

We have used the constructs of environmental congruence as articulated by

Patients Safe" and a Maslovian conceptualization of nurses' psychosocial needs (Maslow,

environment (medical/surgical units) based on the conceptual framework. The following

research questions are posed:

To appreciate as to how the physical environment, nursing work, and nurses'

consider findings of scholars across a number of academic disciplines including nursing,

predictable (Agger, 1998).

Literatures pertaining to physical dimension of hospital nursing work environments

(whether with positivist or non-positivist perspectives) include literature related to:

1) the history of hospital design;

2) contemporary hospital design standards;

3) contemporary research related to hospital design;

4) nursing work as women's work;

5) the physical work environment;

6) WRS and the physical work environment; and

7) Person-Environment Congruence (PE Fit) theory.

provide a context for the present study.

The History of Hospital Design

historiographers also acknowledge that histories of social phenomena are themselves

complex, heterogeneous, subject to reinterpretation, and influenced by the historian's political

The Nightingale Era

The Rise of the Mega Hospital